Provider Demographics
NPI:1881635076
Name:PETERS, TIMOTHY D (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:D
Last Name:PETERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 LYNDON LN STE 6
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4643
Mailing Address - Country:US
Mailing Address - Phone:502-326-8600
Mailing Address - Fax:502-326-8970
Practice Address - Street 1:714 LYNDON LN STE 6
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4643
Practice Address - Country:US
Practice Address - Phone:502-326-8600
Practice Address - Fax:502-326-8970
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY396462084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64105463Medicaid
KY64105463Medicaid
KYI04768Medicare UPIN